chronic disease risk factor monitoring in europe - thl · 2014-05-02 · 28/03/2011 risk factor...

28/03/2011 Risk factor monitoring in Europe 1

Chronic disease risk factor monitoring in Europe

Kari Kuulasmaa, Research Professor, THL

CHD mortality, Men aged 35-64

1950

1952

1954

1956

1958

1960

1962

1964

1966

1968

1970

1972

1974

1976

1978

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

0

100

200

300

400

500

600

700

/100 000

KTL/ETEO/HT/2004 Data source: WHO Mortality Database Age standardized to European standard population

FIN

USA

RUS

HUNUK

SWE

SPA

FRAJPN


Population level risk factor monitoring

• Registry data

– Not very useful

• Questionnaire surveys

– Self-reported information

– Cheaper than examination surveys

• Examination surveys

– Only source for many risk factors

– Objective information


Interview /questionnaire surveys (HIS)

• CINDI health monitor

– Health knowledge, attitudes and behaviour

• European Health Interview Survey (EHIS)

– Piloting and first round 2005-

– All EU countries 2014-

http://circa.europa.eu/Public/irc/dsis/health/library?l=/methodologiessandsdatasc/healthsinterviewssurvey/2007-2008_methodology&vm=detailed&sb=Title


Contents of EHIS

• Background variables

• Health status

• Health care– Measurement of blood pressure, cholesterol, glucose

– Cancer screening

• Health determinants– Weight, height

– Physical activity

– Consumption of fruit and vegetables

– Environmental exposures

– Smoking

– Alcohol

– Drugs


Health Examination Surveys (HES)

• National surveys from early 1960s, increasing in numbers

• WHO MONICA Project 1980s-1990s– www.ktl.fi/monica

• European Health Risk Monitoring (EHRM) Project– Updated the MONICA protocol in 2002

– www.ktl.fi/ehrm

• European Health Examination Survey (EHES)– Feasibility study in 2006-2008

• www.ktl.fi/fehes

– Implementation 2009-• www.ehes.info

http://www.ktl.fi/monica

http://www.ktl.fi/ehrm

http://www.ktl.fi/fehes

http://www.ehes.info/

28/03/2011 Risk factor monitoring in Europe

7

History of HESs in Europe

1960 1970 1980 1990 2000

Finland

Sweden

Norway

Netherlands

West Germany

Germany

UK -England

UK -Scotland

Ireland

Poland

Denmark

RomaniaSpainCroatia

France

Czech Republic




• WHO MONICA Project 1980s-1990s– www.ktl.fi/monica

• European Health Risk Monitoring (EHRM) Project– Updated the MONICA protocol in 2002

– www.ktl.fi/ehrm

• European Health Examination Survey (EHES)– Feasibility study in 2006-2008


– Implementation 2009-• www.ehes.info






WHO MONICA Project

Multinational MONitoring of trends and determinants

in CArdiovascular disease

• Monitoring of cardiovascular disease mortality, morbidity, medical care and risk factors in different populations over a period of 10 years

• Assessment of the relationship between the trends observed in mortality, morbidity, risk factors and medical care


WHO MONICA Project populations

The WHO MONICA Project Circulation 1994; 90(1):583-612

WHO MONICA Project Lancet, 1999; 353: 1547-1557 CORMORANT 2


Prevalence of daily cigarette smoking (%).Age group 35-64, age standardized. Final survey.

CHN-BEIRUS-NOCRUS-NOIPOL-TAR

POL-WARYUG-NOSBEL-CHA

RUS-MOCGER-BREDEN-GLOBEL-GHERUS-MOISPA-CATUNK-GLACZE-CZESWI-TIC

GER-AUULTU-KAU

ITA-BRIFRA-LIL

CAN-HALFIN-KUOFIN-TULITA-FRI

UNK-BELFIN-NKASWI-VAF

GER-EGESWE-GOTGER-AURFRA-TOUAUS-PERFRA-STR

ICE-ICEUSA-STA

AUS-NEWSWE-NSWNEZ-AUC

0 20 40 60 80 100

MEN

DEN-GLOUNK-GLAPOL-WAR

ICE-ICEGER-BREYUG-NOSBEL-CHA

SWE-GOTSWE-NSWBEL-GHE

SWI-TICGER-AUUCAN-HALSWI-VAFUNK-BELCZE-CZE

ITA-BRIITA-FRI

FRA-TOUPOL-TARUSA-STAFIN-TULFRA-LIL

AUS-NEWGER-AURSPA-CATFRA-STRNEZ-AUCRUS-MOI

RUS-MOCFIN-KUO

AUS-PERFIN-NKA

GER-EGECHN-BEIRUS-NOI

RUS-NOCLTU-KAU

0 20 40 60 80 100

WOMEN

WHO MONICA Project Lancet, 2000; 355: 675-687 EARWIG 5


10-year trend in percentage of daily cigarette smokers.

Age group 35-64, age standardized, with 95% confidence interval

USA-STAITA-BRI

FRA-TOUUNK-GLAFRA-STR

AUS-NEWGER-EGENEZ-AUCAUS-PERSPA-CAT

POL-WARCZE-CZE

SWE-GOTUNK-BELSWI-VAF

ITA-FRIFRA-LIL

GER-AURFIN-KUOSWI-TIC

LTU-KAUFIN-NKA

POL-TARICE-ICE

BEL-CHASWE-NSWRUS-MOCDEN-GLO

FIN-TULBEL-GHERUS-NOCGER-AUUGER-BREYUG-NOSRUS-MOICAN-HALRUS-NOICHN-BEI

-30 -20 -10 0 10 20 30

MEN

USA-STAUNK-BELNEZ-AUCUNK-GLA

ICE-ICECHN-BEI

AUS-PERAUS-NEWSWE-GOTGER-EGE

ITA-FRICAN-HAL

POL-WARFRA-STRDEN-GLOGER-BRELTU-KAUFIN-TUL

RUS-MOCRUS-MOI

SWE-NSWRUS-NOCFIN-KUOSWI-TIC

CZE-CZEFIN-NKA

GER-AURYUG-NOSFRA-TOU

FRA-LILSWI-VAF

ITA-BRIBEL-GHERUS-NOI

GER-AUUBEL-CHASPA-CATPOL-TAR

-30 -20 -10 0 10 20 30

WOMEN



Mean systolic blood pressure (mmHg). Age group 35-64, age standardized. Final survey.

FIN-NKAGER-EGEFIN-KUOITA-FRIFIN-TUL

LTU-KAUCZE-CZEGER-AUUYUG-NOSGER-AURFRA-STRRUS-NOIUNK-BEL

FRA-LILAUS-PER

SWE-GOTPOL-TARRUS-MOIUNK-GLAPOL-WARSWI-VAF

GER-BRESWI-TIC

RUS-NOCCHN-BEI

AUS-NEWBEL-CHA

ITA-BRISWE-NSWRUS-MOCCAN-HALBEL-GHEUSA-STANEZ-AUCDEN-GLOFRA-TOU

ICE-ICESPA-CAT

100 110 120 130 140 150

MEN

FIN-KUOGER-EGE

FIN-NKAYUG-NOSRUS-NOIFIN-TULITA-FRI

LTU-KAUPOL-TARCZE-CZERUS-MOIRUS-MO

RUS-NOCGER-AUUCHN-BEISWE-GOUNK-BELGER-AUR

FRA-LILGER-BREPOL-WARAUS-NEWFRA-STR

ITA-BRIUNK-GLASWE-NS

CAN-HALAUS-PERBEL-CHASWI-VAFSWI-TIC

NEZ-AUCBEL-GHEDEN-GLO

ICE-ICEUSA-STASPA-CATFRA-TOU

100 110 120 130 140 150

WOMEN



10-year trend in systolic blood pressure (mmHg).


POL-WARGER-BRERUS-MOIFRA-STR

ITA-BRIFIN-KUO

RUS-MOCFRA-TOU

FRA-LILUNK-GLANEZ-AUC

FIN-TULSPA-CATSWI-TICITA-FRI

FIN-NKADEN-GLO

SWE-NSWCZE-CZEUSA-STA

AUS-NEWAUS-PERRUS-NOC

ICE-ICERUS-NOI

GER-AURPOL-TARSWI-VAFBEL-CHAYUG-NOSLTU-KAU

GER-EGECHN-BEI

GER-AUUUNK-BEL

SWE-GOTBEL-GHECAN-HAL

-20 -15 -10 -5 0 5 10 15

MENPOL-WARGER-BRERUS-MOIFRA-STR

RUS-MOCFRA-TOU

SWI-TICUNK-GLA

ITA-BRIFIN-KUOFRA-LILFIN-NKA

SPA-CATITA-FRI

USA-STADEN-GLO

SWE-NSWGER-AURSWI-VAFLTU-KAUFIN-TUL

CZE-CZERUS-NOCNEZ-AUCAUS-PERPOL-TARGER-EGEUNK-BEL

AUS-NEWBEL-CHABEL-GHEGER-AUURUS-NOIICE-ICE

SWE-GOTCHN-BEI

YUG-NOSCAN-HAL

-20 -15 -10 -5 0 5 10 15

WOMEN



Mean total cholesterol (mmol/l).Age group 35-64, age standardized. Final survey.

SWI-TICYUG-NOSSWI-VAFSWE-NSICE-ICE

GER-AUUGER-BREBEL-CHACZE-CZE

GER-AURUNK-GLABEL-GHEFIN-NKA

FRA-STRFIN-KUOLTU-KAU

DEN-GLOITA-BRI

UNK-BELFIN-TULITA-FRIFRA-LIL

FRA-TOUGER-EGEAUS-NEWPOL-WARNEZ-AUCCAN-HALSPA-CATPOL-TAR

SWE-GOTAUS-PERUSA-STARUS-NOIRUS-MOI

RUS-MOCRUS-NOCCHN-BEI

4 4.5 5 5.5 6 6.5 7

MEN

LTU-KAUSWI-TIC

YUG-NOSGER-BRECZE-CZESWE-NS

BEL-CHAUNK-GLASWI-VAFICE-ICE

BEL-GHEGER-AURGER-AUUUNK-BELFRA-STR

ITA-BRIFRA-LIL

DEN-GLOGER-EGECAN-HALFIN-KUOFIN-NKAFIN-TULITA-FRI

POL-WARFRA-TOUAUS-NEWNEZ-AUC

RUS-MOCSPA-CATPOL-TARRUS-MOI

SWE-GOTRUS-NOIAUS-PERRUS-NOCUSA-STACHN-BEI

4 4.5 5 5.5 6 6.5 7

WOMEN



FRA-LILRUS-NOCSWE-GOT

ITA-FRIRUS-MOIFIN-KUOCAN-HALFIN-NKAFIN-TUL

RUS-NOIRUS-MOCCZE-CZEBEL-GHEUNK-GLAAUS-PERSPA-CAT

GER-EGEUNK-BELSWI-VAFUSA-STAFRA-TOUGER-AUUGER-AURAUS-NEWLTU-KAUSWE-NS

DEN-GLONEZ-AUCBEL-CHA

ICE-ICEGER-BREPOL-WARPOL-TARCHN-BEIFRA-STR

ITA-BRIYUG-NOS

SWI-TIC

-1.5 -1 -0.5 0 0.5 1 1.5 2

MEN

10-year trend in total cholesterol (mmol/l).


SWE-GOTRUS-NOC

FRA-LILFIN-NKAITA-FRI

RUS-NOIFIN-KUOFIN-TUL

RUS-MOIAUS-PERUNK-GLACZE-CZE

ICE-ICERUS-MOCUNK-BELNEZ-AUCGER-AUUGER-EGESPA-CAT

AUS-NEWFRA-TOUSWE-NS

DEN-GLOSWI-VAFCAN-HALGER-AURBEL-GHEUSA-STAPOL-TARLTU-KAU

POL-WARGER-BREBEL-CHACHN-BEIFRA-STR

YUG-NOSITA-BRI

SWI-TIC

-1.5 -1 -0.5 0 0.5 1 1.5 2

WOMEN



AUS-NEWGER-AURCZE-CZECAN-HALFIN-NKA

FRA-STRFIN-KUO

YUG-NOSFIN-TUL

GER-AUUBEL-CHA

POL-WARLTU-KAU

GER-EGEUSA-STA

ITA-FRIICE-ICE

UNK-GLAGER-BRENEZ-AUCSPA-CATSWI-VAFSWI-TICITA-BRI

AUS-PERSWE-NSW

FRA-LILBEL-GHEUNK-BEL

SWE-GOTRUS-NOIFRA-TOUDEN-GLORUS-NOCPOL-TARRUS-MOI

RUS-MOCCHN-BEI

20 22 24 26 28 30

MEN

2

RUS-NOIRUS-NOCPOL-TARLTU-KAU

YUG-NOSCZE-CZECAN-HAL

POL-WARSPA-CAT

AUS-NEWFIN-KUOFIN-NKA

UNK-GLAGER-AURBEL-CHAUSA-STAGER-AUURUS-MOC

FRA-LILGER-EGERUS-MOIGER-BRE

ICE-ICEFIN-TUL

FRA-STRAUS-PERBEL-GHE

ITA-FRISWE-NSWNEZ-AUCUNK-BEL

ITA-BRISWI-TIC

SWE-GOTSWI-VAF

DEN-GLOFRA-TOUCHN-BEI

20 22 24 26 28 30

WOMEN

Mean Body Mass Index (kg/m ).Age group 35-64, age standardized. Final survey.

2



RUS-MOISWI-TIC

RUS-MOCLTU-KAU

RUS-NOCFRA-STRGER-AUURUS-NOICZE-CZEDEN-GLO

FIN-TULSWI-VAF

GER-BREITA-FRI

POL-WARGER-AURFRA-TOUFIN-KUOUNK-BELGER-EGE

FRA-LILPOL-TARBEL-CHAYUG-NOSBEL-GHEFIN-NKA

CAN-HALSWE-NSW

SPA-CATAUS-PERCHN-BEI

SWE-GOTITA-BRI

NEZ-AUCICE-ICE

UNK-GLAUSA-STA

AUS-NEW

-4 -3 -2 -1 0 1 2 3 4

MEN

10-year trend in BMI (kg/m ). Age group 35-64, age standardized, with 95% confidence interval

2

RUS-MOCRUS-MOILTU-KAU

RUS-NOCCZE-CZE

ITA-FRIFRA-STRBEL-CHAYUG-NOSSWI-VAFRUS-NOIFRA-TOUBEL-GHEFIN-NKASWI-TICCHN-BEIUNK-BELGER-BREPOL-WARGER-AUR

SWE-NSWFIN-TUL

DEN-GLOITA-BRI

SPA-CATGER-AUUGER-EGESWE-GOTPOL-TARFIN-KUO

UNK-GLAFRA-LIL

NEZ-AUCAUS-PER

ICE-ICEAUS-NEWUSA-STACAN-HAL

-4 -3 -2 -1 0 1 2 3 4

WOMEN



FRA-LILRUS-MOI

RUS-NOCFIN-KUO

RUS-MOCITA-FRI

FRA-TOUSWE-GOTUNK-GLAPOL-WAR

FIN-TULSPA-CATCZE-CZEFIN-NKA

GER-BREAUS-PERUSA-STANEZ-AUCGER-EGEFRA-STRSWI-VAF

AUS-NEWRUS-NOIUNK-BELLTU-KAUGER-AURDEN-GLOSWE-NS

CAN-HALITA-BRI

GER-AUUBEL-CHABEL-GHE

ICE-ICEPOL-TARCHN-BEI

YUG-NOSSWI-TIC

-0.6 -0.3 0 0.3 0.6

MEN

10-year trend in risk score. Age group 35-64, age standardized, with 95% confidence interval

RUS-MOIPOL-WARUNK-GLAGER-BRERUS-MOC

ITA-FRIFIN-KUOFRA-LILFIN-NKA

FRA-TOUAUS-PERUSA-STA

SWE-GOTNEZ-AUCUNK-BEL

RUS-NOCFIN-TUL

GER-EGEAUS-NEWDEN-GLOCZE-CZEFRA-STR

ICE-ICESWE-NS

SPA-CATRUS-NOISWI-VAF

GER-AURLTU-KAU

ITA-BRIBEL-GHEGER-AUUCHN-BEIPOL-TARBEL-CHASWI-TIC

CAN-HALYUG-NOS

-0.6 -0.3 0 0.3 0.6

WOMEN





• WHO MONICA Project 1980s-1990s

– www.ktl.fi/monica

• European Health Risk Monitoring (EHRM) Project

– Updated the MONICA protocol in 2002

– www.ktl.fi/ehrm

• European Health Examination Survey (EHES)

– Feasibility study in 2006-2008


– Implementation 2009-

• www.ehes.info





28/03/2011 Risk factor monitoring in Europe

22

Results of FEHES

http://www.ktl.fi/fehes/


European Health Examination Survey

• To provide info on health behaviour, health determinants, prevalence of diseases, met and unmet need for health services, functional limitations and nutritional status

• For planning and evaluation of health policies and health care, and for research

• Complementary to EHIS


EHES target population

• Entire country

• Permanent residents, including institutionalized persons

• Core age group: 25-64 years

• Can extend to 18+


EHES sampling

• Two stage sampling

• Sample of areas within the country

• Sample of individuals within the area

• Sample size

• At least 4000 persons

• About equal sample size for each area

• Equal sample size for each sex and age stratum


Selection of HES measurements

• Based on:• Epidemiological and public health

criteria• Availability of international standards

• Existing recommendations:• ECHI list;• Other Projects of the Public Health

Programme;• EHRM; • WHO STEPS.


Core measurements

Examinations Questions

• Height

• Weight

• Waist circumference

• Blood pressure

• Blood samples (non-fasting,e.g. for total-, HDL-cholesterol…)

• Fasting blood samples (e.g.for glucose)

• Age

• Sex

• Education

• [Occupation/income]

• General health/ generalhealth status

• CVD

• Hypertension

• Hyper/dyslipidemia

• Diabetes

• Smoking


Additional measurements

Examinations Questions

• Hip circumference

• Ankle/brachial index

• Physical fitness test

• Lung function test

• Physical performance/ functional test (e.g. walking speed test, vision test, hearing test, hand grip test)

• Cognitive function test

• ECG

• Urine sample (glucose, cotinine)

• Saliva test (alternative for cotinine)

• Bone density

• Other items pertaining to research questions at local level

• Physical activity

• Drinking

• Use of health services (general)/ medication

• Social support

• Psychological distress

• Respiratory disease (e.g. COPD, asthma)

• Use of health services (for special conditions)

• Use of contraception and HRT

• Diet: fruit & vegetable consumption

• Mental health

• Oral health

• Other items pertaining to research questions at local level


Criteria for inclusion

Inclusion

in

previous

national

HESs

Practicality Acceptability Low

cost

International

standards

availability

Clear

interpretation

of results

Height +++ +++ +++ +++ +++ +++

Weight +++ +++ ++ +++ +++ +++

WC +++ ++ ++ +++ +++ +++

BP +++ ++ ++ ++ +++ +++

Blood

sample

++ ++ + * +++ +++

Physical

fitness test

+ ++ ++ ++ + +

Lung

function test

+ ++ ++ ++ +++ ++

Physical

performance

+ ++ ++ +++ + ++

Cognitive

function test

++ ++ ++ +++ ++ ++

Urine

sample

+ ++ + * * *

Saliva

sample

+ ++ ++ * * *

ECG + + ++ + ++ ++

Bone

density

+ + ++ + ++ ++


Setting up EHESPhase I

Setting up EHES RC

EHES Manual and national HES manuals

Training programme

Planning and preparing national HES, including a pilot survey in 13 countries

Phase I

I Full-size HES in 13 pilot countries

Planning and preparing national HES in rest of the European countries

Development to a sustainable HES system

0 4321

Funding from the DG Sanco


Pilot countries

Finland

Germany

Netherlands

Poland

Czech Republic

Slovakia

Greece

Italy

MaltaSpain

Portugal

UK/England

Norway


Comparability between surveys

within a country

between countries

Comparability with previous surveys

within a country

Training

Challenges for EHES

• Sampling frame and sampling

• Participation rate

• Quality of measurements

chronic disease risk factor monitoring in europe - thl · 2014-05-02 · 28/03/2011 risk factor...

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